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Introduction

Crohn’s disease (CD) is a continuing inflammatory disorder affecting the gastrointestinal tract (GIT). The disease can affects people irrespective of their age. The terminology “Crohn’s disease” replaced other older terms that were used to describe the disease which included regional ileitis, terminal ileitis, regional enteritis, and granulomatous colitis. The most commonly affected sites are the terminal ileum and the right colon; however, similar pathological as well as proven disorders can affect part (s) of the GIT; from the mouth to the perianal area. Many patients diagnosed with CD get anxious with the mention ileostomy leading to psychological distress. This paper comprehensively examines Crohn’s disease, Pre-operative, and post-operative management of clients as well as how nurses can provide emotional support to their patients and the entire family during this life altering experience (Cheifetz p.1708).

Clinical presentation of Crohn’s disease

Diagnosing CD can be challenging since it’s widespread and often has ambiguous manifestations. The clinical features of the disease vary depending on the affected site but include the following:

  • Chronic diarrhea for more than four weeks; with or without mucus.
  • Abdominal pain
  • Weight loss

Patients presenting with the above three symptoms should initially have blood samples taken for testing.

More than ninety percent (90%) of the patients experience symptoms before they reach forty years. These patients mostly present with diarrhea, abdominal cramps, and stuck growth (this is mostly a case for pre-pubescent patients), weight loss, anemia, fever, perianal fistula and an abdominal mass in the right lower quadrant (If complications have developed in the ileal region) (Sathiyasekaran and Shivbalan pp. 723-729).

Normally, patients with ileitis or ileocolitis have a stealthy start and a prolonged progression before they can get a precise diagnosis. The middling duration of the symptoms before a specified diagnosis is made and therapy started was initially 2-3 years, but this has significantly reduced due to advancements in imaging techniques such as computed tomography and ultrasonography.

Crohn’s disease have many patterns of manifestation; ileitis, colitis, jejunoileitis, and ileocolitis. Each of these subtypes has distinctive clinical presentation. Patients with ileum and jejunum inflammation present with abdominal pain and cramping after meals that eventually lead to diarrhea. These patients may also experience projecting extra-intestinal manifestations such as arthritis, delayed growth, fever, and skin lesions. Ileitis leads to uneasiness 1-2 hours subsequently after meals. The weight loss is due to the fact that patients eat not as much to avoid the uneasiness. The inflammation in the ileum can spread into neighboring structures causing abscess of perforations. Some patients also develop bowel obstruction eight to ten years after the commencement of the disease; this is due to the narrowing of the lumen of the bowel as a result of muscle hypertrophy and fibrosis. Generally, the clinical progression of the disease depends on the area(s) of the bowel that is involved (Sathiyasekaran and Shivbalan pp. 723-729).

Pathophysiology of Crohn’s disease

The predominant hypothesis on the pathogenesis of Crohn’s disease majors on the interaction between an altered immune system and environmental factors in genetically predisposed individuals, which leads to chronic inflammation of the GIT. In Crohn’s disease there is a disorderly regulation of the mucosal and systematic immune system which results in continuation of the inflammation. A deregulated TH1 response (T helper 1) is very crucial in the conversion of physiologic to pathologic inflammation (Sathiyasekaran and Shivbalan pp. 724-725).

The immunological profile in Crohn’s syndrome is majorly a cell-mediated response. An active mucosal inflammation of the small and the large intestines result in diarrhea, bleeding, abdominal pain, protein-losing enteropathy, and stricture formation. Pro-inflammatory cytokines and eicosanoids increase vascular permeability leading to electrolyte secretion, and increase smooth muscle contraction. Numerous cytokines lead to the recruitment and increased activity of collagen forming cells leading to fibrous tissue proliferation thereby resulting in thickening of the bowel wall and stricture formation (Sathiyasekaran and Shivbalan pp. 724-725).

Role of diet and medication in management of Crohn’s disease

Medical therapy

Medication is based on the severity of the disease and the extent to which the GIT is involved. This varies throughout the progression of the disease. Correct assessment of these factors is vital in determining the treatment (Fatahi, Al Asmari and Bukhari p. 2006). The following medications can be used depending of the severity of the disease.

Anti-inflammatory drugs

Mild to moderate CD responds positively to 5-aminosalicylic acid (5-ASA) products (mesalamine, mesalazine, and sulfasalazine). These offer anti-inflammatory actions to the connective tissue along the GIT. Asacol, releases 5-ASA in the distal ileum and colon, Sulfasalazine acts as the transport mechanism to carry the 5-ASA component to the colon tract. Pentasa is comprised of coated granules that release 5-ASA in the upper GIT, as well as the ileum and colon. Amino-salicylates have several anti-inflammatory effects that are primarily topical (mucosal); they also hinder oxygen radical production.

Antibiotics

Antibiotic treatment can be used in the management of Crohn’s disease regardless of the fact that microbial agents have not been recognized as specific etiological factors. Metronidazole is the commonly used antibiotic and its effectiveness is comparable to sulfasalazine. Metronidazole has been successful in treatment of perianal disease and has reduced recurrence of the disease process after ileal resection. Ciprofloxacin is also effective as mesalamine in cases of mild to moderate CD and can be used in combination with metronidazole for ileal and perianal disease (Fatahi, Al Asmari and Bukhari p. 2006).

Steroid Drugs

Adrenocorticosteroids such as prednisone (40–60 mg/d), in combination with other anti-inflammatory drugs such as sulfasalazine or mesalamine, improve symptoms during the first 4–5 years of uncomplicated CD or during a post-resection recurrence. Patients with cases of predominantly ileal involvement are the most responsive. However, it is vital to monitor patients on chronic steroid therapy for indication of bone degradation. If there is evidence of osteopenia or osteoporosis, therapy with a bisphosphonate or calcitonin is indicated (Cheifetz p. 1708)

Immuno-modulator Drugs

Immuno-modulator therapy (azathioprine and 6-mercaptopurine [6-MP]) can be used to treat inflammatory bowel disease. These drugs are thought to alter the immune response by inhibition of natural killer cell activity and suppression of T-cell function. Immuno-modulator therapy has been shown to be more effective than steroids as a maintenance therapy and is generally well tolerated. Immuno-modulators are recommended for patients with disease stubborn to conventional therapy.

Diet

Patients with small-bowel Crohn’s disease can be managed using elementary diets composed of simple sugars and amino acids that do not require any digestion at all. These diets alter the intestinal luminal contents thus providing temporary relief while medical therapy is commenced. Enteral nutrition involves monomeric, oligomeric, or polymeric diets. It’s used for 1-2 months (Cheifetz p. 1708). It may provide temporary relief. There is no significant difference between the diets. Total parenteral nutrition therapy can also be initiated for 2-3 weeks in medically refractory patients. Nutrition therapies help correct nutritional deficits especially in patients with chronically active Crohn’s disease. However, it must be supported by additional medical therapy such as an immune-modulator. This prevents patients from relapsing once they resume enteral feeding.

Pre and post-operative management and care needed for a person who has surgery to create an ileostomy

An ileostomy is defined as a stoma formed on the portion of the ileum. On average, this procedure requires one litre of fluid effluent on a daily basis for successful management. The patient is required to wear a drainable appliance to assist in emptying the contents approximately 4-6 times a day (Vujnovich pp. 50-56).

Ileostomy patients need to manage their diet and fluid intake carefully. Fibrous foods are not recommended because they can lead to small bowel obstruction and risk dehydration. Careful attention should also be given to the patient because they are prone to skin maceration, excoriation, as well as leakage due to the nature of liquid output. A well-constructed ileostomy accompanied by competent and compassionate nursing management and education will make sure there is a positive outcome both for the patient and the family. Information is very important in each and every stage of this process (Vujnovich pp. 50-56).

Pre-operative care

Information in this stage needs to centre on the nature of the surgery and the expected course of the operation. After meeting the information needs of the patient, the nurse then focuses on emotional support. In this stage, the patient depends on the health care providers to meet all of her needs. Martina requires patience, understanding and repeated explanations to dispel her nervousness and anxiety (Vujnovich pp. 50-56).

Siting and marking the patient the patient before the surgery is very important because a poorly sited stoma can lead to poor functional outcomes for the patient. Avoid bony prominences when siting the stoma. Other areas to avoid include body creases, folds, scars, and the umbilicus. It is also advisable to avoid the waistline and areas of radiation therapy. Correct site marking plays a big part in reducing incidences of post-operative complications (Vujnovich pp. 50-56). Pre-operative teaching on operation outcomes is very important at this stage. Pre-operative teaching by a specialized nurse greatly improves the overall outcomes plus other factors relating to quality of life, acquisition of skills, and long term adjustments to the stoma.

Before the surgery, the nurse also needs to assess the person about to undergo the surgery. This forms part of the pre-operative preparation that the patient is required to go through. The following areas are vital in this assessment: surgical and medical history, diagnosis and education on the procedure to be done. Evaluations are also done on the individual’s support system, cultural and spiritual issues relating to the patient, her hobbies, vision, hearing, motor skills, skin sensitivity, and other physical challenges; this ensures optimal care outcomes for the patient (Vujnovich pp. 50-56).

Post-operative care and management

Post-operatively, Martina needs information relating to self-care methods and emotional support to come to terms and adjust to her new method of toileting. She requires assistance to agree to the new arrangements and integrate them into her self-image and her lifestyle.

The stoma therapy nurse has the largest time commitment in this pre-operative stage as it plays a big role on how the individual cope with her new lifestyle. This involves assisting the individual in the rehabilitation process in several ways. The most important activity at this phase, right after the procedure it teaching the individual to manage her stoma and related appliances (Vujnovich pp. 50-56). This entails pouch changing and equipping Martina with comprehensive information and skills to complete her daily living activities.

The patient needs a pouching system that best suits their body contours that will provide a leak free system, and also learn which appliances to use that protect her skin integrity. These skills and knowledge are not fast to learn and therefore a close follow-up by a nurse that includes all elements involving stoma care that facilitate independent living is important. The nurse also has a vital role in managing complications associated with ileostomy such as retraction, herniation, stoma necrosis, and stenosis.

Client and family teaching

While caring for an ileostomy patient, it is important to explain the operation to the client. Patient education should be instantaneous and continuing to ease acceptance and patients’self-care. Teach the patient on how to manage the pouch clamp, empty, rinse, and change the pouch. Self-care plays a vital role to independence and self-esteem. Teach the individual on how to check the stoma as well as the peristomal skin after each and every pouch change (Vujnovich pp. 55-56). Also instruct the individual to report any abnormalities in appearance of the stoma and the surrounding skin.

Discuss the importance of sufficient water and salt intake with the client and her family; mostly during hot weather. Fluid loss affects ileostomy drainage. The intake of water should be sufficient to maintain pale urine, extra water and salt intake should be done when the client is exercising. Advise the client and her family to take foods high in potassium such as bananas and oranges. Discuss dietary concerns with both the patient and her family. A diet low in residue is recommended in the initial stages. Instruct the client to also avoid foods that can cause excessive odour and gas. Finally, teach on self-care measures in cases of food blockage, for example, taking a warm shower or tube bath, drinking warm fluids, and massaging the peristomal region (Vujnovich pp. 55-56).

Conclusion

Crohn’s disease is typically manageable with therapeutic treatment. However, numerous patients require undergoing surgery (for example ileostomy) at least on one occasion. Awareness of clinical as well as histological subtypes of the disease is very vital in providing a comprehensive and effective management plan. Ileostomy or any other stoma-forming operation is a life-altering procedure that can be very distressing (both physically and emotionally) to an individual. An individual undergoing this procedure therefore requires pre-operative as well as post-operative management from a specialized. The nurse is therefore required to have adequate information and management skills as it’s a life-long support involved.

References

Chandler, P., & Lowther, C. (2013). Stoma care: the use of loperamide in ileostomy care. Gastrointestinal Nursing11(4), 11-12. doi: 10.12968/gasn.2013.11.4.11

Cheifetz, A. (2013). Management of Active Crohn Disease. JAMA309(20), 2150. doi: 10.1001/jama.2013.4466

Cheifetz, A. (2014). Crohn Disease. JAMA312(16), 1708. doi: 10.1001/jama.2014.7962

Fatahi, D., Al Asmari, A., & Bukhari, G. (2018). Crohn's Disease : Pathophysiology and Management. The Egyptian Journal Of Hospital Medicine70(11), 2004-2007. doi: 10.12816/0044858

Sathiyasekaran, M., & Shivbalan, S. (2010). Crohn’s disease. The Indian Journal Of Pediatrics73(8), 723-729. doi: 10.1007/bf02898453

Vujnovich, A. (2008). Pre and post-operative assessment of patients with a stoma. Nursing Standard22(19), 50-56. doi: 10.7748/ns2008.01.22.19.50.c6315

Wall, C. (2016). Dietitian Experience with Exclusive Enteral Nutrition for the Treatment of Crohn Disease. Journal Of Nutritional Medicine And Diet Care2(1). doi: 10.23937/2572-3278.1510015

Zoppis, E. (2015). A hidden pathology: Crohn disease. Clinical Management Issues5(2S), 59. doi: 10.7175/cmi.v5i2s.1113

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